- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,000.00 / $3,576.00 / $8,400.00
| Facility | | $1,000.00 | $3,576.00 | $8,400.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $138.68 / $138.68 / $138.68
| Professional | | $138.68 | $138.68 | $138.68 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $138.68 / $1,239.00 / $9,412.67
| Facility | | $138.68 | $1,239.00 | $9,412.67 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $156.05 / $235.51 / $1,508.16
| Professional | | $156.05 | $235.51 | $1,508.16 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,481.00 / $5,407.00 / $9,232.95
| Facility | | $1,481.00 | $5,407.00 | $9,232.95 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $143.50 / $197.31 / $326.08
| Professional | | $143.50 | $197.31 | $326.08 |